- Email: [email protected]
Redoing reconstruction of the esophagus using remnants of the ileo-left colon aided by microvascular anastomosis
Ann Thorac Surg 2001;71:1695–7
Comment Cooper reintroduced the idea of LVRS in patients with severe emphysema [2]. To reduce postoperative air leaks, he buttressed his staples with bovine pericardium, which is frequently used in surgery due to its biocompatibility. However, Iwasaki and colleagues describe two patients who developed interstitial pneumonia at the bovine pericardial patches 3 months after LVRS [3]. They therefore, modified their technique to a fold plication technique obviating the need for buttressing. It would be interesting to know whether synthetic buttresses cause the same degree of interstitial pneumonitis. In an animal study, the tissue response to polytetrafluoroethylene (PTFE) and bovine pericardium for staple-line reinforcement was compared. After 30 days, only the pericardial specimens showed focal chronic inflammation [4]. In some centers unbuttressed staples are used in LVRS. However, in a prospectively randomized study comparing buttressed with unbuttressed staples, the postoperative air leak was 2.5 days longer in the group without buttresses [5]. It may be that the staples rather then the buttresses are the cause of the inflammation. Horio and associates described a patient who developed hemoptysis 3 months after a VAT bullectomy [6]. The staples were found to have caused a hematoma with resulting inflammation. Therefore, biodegradable staples may be a solution [7]. However, total disappearance occurs only after 6 to 7 months, which may not be soon enough to prevent this type of complication. Other techniques, such as laser ablation, have been developed to avoid the use of staples. Ultrasonic dissection has not been used routinely in LVRS but may be an alternative. In line with the introduction of a new surgical technique, we have coined a new term for a new complication; “metalloptysis,” coughing up of metal.
References 1. Saunders MS, Cropp AJ, Awad MJ. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma 1992;33:909–11. 2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19. 3. Iwasaki M, Nishiumi N, Kaga K, Kanazawa M, Kuwahira I, Inoue H. Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema. Ann Thorac Surg 1999;67:815–7. 4. Vaughn CC, Vaughn PL, Vaughn CC 3rd, Sawyer P, Manning M, Anderson D. Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 1998;13:259– 65. 5. Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573–5. 6. Horio H, Nomori H, Fuyuno G, Kobayashi R, Castel-Dupont S. Intrapulmonary hematoma surrounding the stapled line after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax. Kyobu Geka 1999;52:477– 80. 7. Nguyen H, Nguyen HV, Barra JA, Raut Y, Morinaga S, © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
1695
Suemasu K. Absorbable synthetic clips and pulmonary excision. Our clinical experience. Chir (Paris) 1987;124:113– 8.
Redoing Reconstruction of the Esophagus Using Remnants of the Ileo-Left Colon Aided by Microvascular Anastomosis Yau-Lin Tseng, MD, Ming-Ho Wu, MD, Mu-Yen Lin, MD, and Jing-Wei Lee, MD Divisions of Thoracic Surgery and Plastic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.
Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury. (Ann Thorac Surg 2001;71:1695–7) © 2001 by The Society of Thoracic Surgeons
T
he substitutes most commonly used for replacement of the esophagus include portions from the stomach, colon, and jejunum [1, 2]. On patients with corrosive injury in which the stomach is also frequently injured, the colon or jejunum is the best choice of graft material [3]. However, in cases involving failure of the colon graft or injury to the neoesophagus, surgeons may choose pedicled intestine, extended jejunum, or other flaps for reconstruction [4, 5]. We present a case in which we used remnant ileo-left colon for a second reconstruction of the esophagus. Although severe adhesions in the abdominal cavity may be present, reconstruction of the esophagus can be performed with available remnant alimentary tract with the aid of microvascular surgery. A 42-year-old female patient had a history of substernal ileocolon reconstruction for corrosive esophageal stricture ten years before (Fig 1). She was referred to our hospital ten days after drinking Drano drain cleaner for Accepted for publication July 15, 2000. Address reprint requests to Dr Tseng, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd, Tainan, Taiwan; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(00)02306-7
1696
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
Ann Thorac Surg 2001;71:1695–7
side cologastrostomy was then performed. Finally, the end of the remaining intraabdominal ileum was anastomosed to the sigmoid colon (Fig 2). A nasogastric tube was put into the stomach via the ileo-colon graft. Feeding was started on the 5th postoperative day. Esophagography revealed good passage of contrast medium on the 10th postoperative day. The patient started oral feeding on the 12th postoperative day. Wound infection was the only complication. After debridement and secondary closure of the wound, she was uneventfully discharged on the 27th postoperative day. She was able to swallow a regular diet and stool passage was occurring two to three times per day at the six-month follow-up.
Comment
Fig 1. The ileocolon interposition was performed ten years prior. Gray hatched area was resected on the second incidence of corrosive injury at our hospital.
In the 420 caustic injured patients at our hospital during the past 12 years, only three attempted suicide a second time with a corrosive agent. This patient was the only survivor. In treatment of corrosive esophageal stricture, we prefer to use the colon or ileo-colon as graft material for initial reconstruction because the stomach is always injured. Jejunum should be used as a backup when the colon graft is not available. We initially decided to use jejunal transposition for reconstruction in this patient. After lysis of the abdominal adhesions and careful evaluation of the jejunum, ileum, and colon, we found that the remaining left colon, which was supplied by the left
the second time. In the emergency department, she presented with sepsis and dyspnea. Physically, she had tachycardia (112/min), fever (39.2°C), tachypnea (42/min), pale conjuntiva and decreased breathing sounds in the right chest. Chest film revealed right pyopneumothorax. Arterial blood gas analysis showed pH 7.49, PCO2 37.6 mm Hg, PO2 34 mm Hg, Base excess ⫺6.6 mmol/L without oxygen supply. After tube thoracostomy (500 ml of dirty pus was drained), emergency right thoracotomy for resection of the neo-esophagus, decortication, and laparotomy for feeding gastrostomy were performed. The neoesophagus was necrotic and perforated. She did well after the operation and was discharged on the 36th postoperative day. Two and a half months after the second corrosive injury, she was admitted for reconstruction of the esophagus. After dissection of abdominal adhesions via midline laparotomy, we decided to use the remnant ileocolon as an interposed graft for reconstruction. The graft consisted of a segment of pedicled ileum, 12-cm in length, and left colon, 33 cm in length, which was anastomosed in the previous operation. The blood supply of the ileum and left colon graft was dependent on the ileal artery and in situ left colic artery, without an arcade connection between the ileul and left colonic segments. This graft was pulled up in front of the stomach to the neck via the substernal route. The transposed ileum was anastomosed to the esophagus. Then the ileal artery of the ileal pedicle was anastomosed to the transverse cervical artery, and the vein of the ileum was anastomosed to the external jugular vein with interrupted 9 – 0 Propylene; the left colic artery was left in situ. Warm ischemia time of the ileum was 45 minutes. End to
Fig 2. Redoing reconstruction of the esophagus after a second incidence of corrosive injury. (A) Blood vessels of the ileum; (B) previous ileo-colostomy; (C) in situ leftcolic artery dependent colon; and (D) gray hatched area was the graft used in this operation.
Ann Thorac Surg 2001;71:1797– 8
CASE REPORT GRONDIN ET AL ECTOPIC INTRATHORACIC GOITER
1697
colic artery, was doing well but its length was not enough to reach the cervical esophageal stump. In this situation, free intestinal transfer was a choice to add length of the colon graft [6, 7]. To simplify the operative procedure, we chose the remnant ileo-colon instead of a free jejunal transfer. The functional result of this patient is good during outpatient follow-up. We recommend this surgical technique, as a good alternative for reconstructing the esophagus a second time.
References 1. Wilkins EW. Technique of esophageal reconstruction. In: Zuidema GD, ed. Surgery of the alimentary tract. 3rd ed. Philadelphia: WB Saunders, 1991:387– 407. 2. Akiyama H, Hiayama M, Miyazono H. Total esophageal reconstruction after extraction of the esophagus. Ann Surg 1984;182:547–52. 3. Wu MM, Lai WW. Esophageal reconstruction for esophageal stricture or resection after corrosive injury. Ann Thorac Surg 1992;53:798 – 802. 4. Hirabayashi S, Miyata M, Shoji M, et al. Reconstruction of the thoracic esophagus, with extended jejunum used as a substitute, with the aid of microvascular anastomosis. Surg 1993; 113:515–17. 5. Gorbunov GN, Marinichev VL, Volkov ON, et al. Microvascular reconstruction of the esophagus with pedicled small intestine. Ann Plast Surg 1993;31:439– 42. 6. Ong GB, Lam KH, Lam PHM, et al. Resection for carcinoma of the superior mediastinal segment of the esophagus. World J Surg 1978;2:497–504. 7. Spencer PW, Fisher J. Esophageal reconstruction: free jejunal transfer or circulatory augmentation of pedicled intestinal interposition using microvascular surgery. In: Delarue NC, ed. Esophageal cancer-International trends in general thoracic surgery, volume 4. St. Louis: CV Mosby, 1988;30:250 –5.
Thoracoscopic Resection of an Ectopic Intrathoracic Goiter Sean C. Grondin, MD, Percival Buenaventura, MD, and James D. Luketich, MD The Mark Ravitch/Leon C. Hirsch Center for Minimally Invasive Surgery and the Section of Thoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
We report a case of an ectopic intrathoracic goiter in a 79-year-old human. This uncommon finding presented as a symptomatic paratracheal mass that was resected using thoracoscopic techniques without complication. (Ann Thorac Surg 2001;71:1697– 8) © 2001 by The Society of Thoracic Surgeons
M
ediastinal thyroid neoplasms are uncommon tumors that account for approximately 6% of mediastinal masses in adults [1]. Most of these tumors arise secondary to downward growth into the superior mediAccepted for publication June 21, 2000. Address reprint request to Dr Luketich, Section of Thoracic Surgery, University of Pittsburgh Medical Center, C-800 Presbyterian University Hospital, 200 Lothrop St, Suite C 800 PUH, Pittsburgh, PA 15213–3221; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Computed tomography (CT) of the chest demonstrating high attenuation mass within the superior mediastinum between the right subclavian vein and brachiocephalic artery.
astinum from the thyroid gland in the neck (i.e., substernal goiter). Rarely, an ectopic thyroid tumor develops in the thorax distinct from the cervical thyroid gland. We describe a case of an ectopic superior mediastinal thyroid tumor successfully resected via a thoracoscopic approach. The patient, a 79-year-old woman, presented with a one month history of progressive upper back pain. Her past medical history was significant for hypertension and stable coronary artery disease. Physical examination was unremarkable. Bloodwork, including thyroid function studies, was normal. A chest roentgenogram did not demonstrate any significant abnormalities. Computed tomography (CT) of the chest demonstrated a 3 ⫻ 1.5 cm high attenuation mass within the superior mediastinum located between the right subclavian vein and brachiocephalic artery with no evidence of invasion or adenopathy (Fig 1). A sestamibi thyroid scan demonstrated a normal cervical thyroid gland with separate uptake in the right upper mediastinum at the site of the mediastinal lesion (Fig 2). Following a satisfactory preoperative evaluation which included a negative stress thallium test, a thoracoscopic resection was planned. At the time of surgery, bronchoscopy was normal. A double lumen endotracheal tube was placed and the patient positioned in a right lateral decubitus position. A video-assisted approach was chosen using four access ports (three 5 mm and one 10 mm port) carefully positioned in the upper thorax near the axilla to allow visualization of the paratracheal and upper parasternal areas. Dissection posterior to the superior vena cava was performed taking care not to injure the phrenic nerve. Dissection around the right tracheoesophageal groove identified one paratracheal lymph node that was sampled and found to be pathologically negative. A wellencapsulated mass that corresponded to the mass noted on preoperative CT scan was subsequently mobilized. One major feeding vessel arising from the right innominate artery was isolated, clipped, and divided. There was no cervical extension. The mass was removed en bloc without complication. Postoperatively, the patient had an uncomplicated course and was discharged on postoperative day two. The patient was found to be asymptomatic with resolution of her back pain at 1 and 6 months 0003-4975/01/$20.00 PII S0003-4975(00)02298-0
Comment Cooper reintroduced the idea of LVRS in patients with severe emphysema [2]. To reduce postoperative air leaks, he buttressed his staples with bovine pericardium, which is frequently used in surgery due to its biocompatibility. However, Iwasaki and colleagues describe two patients who developed interstitial pneumonia at the bovine pericardial patches 3 months after LVRS [3]. They therefore, modified their technique to a fold plication technique obviating the need for buttressing. It would be interesting to know whether synthetic buttresses cause the same degree of interstitial pneumonitis. In an animal study, the tissue response to polytetrafluoroethylene (PTFE) and bovine pericardium for staple-line reinforcement was compared. After 30 days, only the pericardial specimens showed focal chronic inflammation [4]. In some centers unbuttressed staples are used in LVRS. However, in a prospectively randomized study comparing buttressed with unbuttressed staples, the postoperative air leak was 2.5 days longer in the group without buttresses [5]. It may be that the staples rather then the buttresses are the cause of the inflammation. Horio and associates described a patient who developed hemoptysis 3 months after a VAT bullectomy [6]. The staples were found to have caused a hematoma with resulting inflammation. Therefore, biodegradable staples may be a solution [7]. However, total disappearance occurs only after 6 to 7 months, which may not be soon enough to prevent this type of complication. Other techniques, such as laser ablation, have been developed to avoid the use of staples. Ultrasonic dissection has not been used routinely in LVRS but may be an alternative. In line with the introduction of a new surgical technique, we have coined a new term for a new complication; “metalloptysis,” coughing up of metal.
References 1. Saunders MS, Cropp AJ, Awad MJ. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma 1992;33:909–11. 2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19. 3. Iwasaki M, Nishiumi N, Kaga K, Kanazawa M, Kuwahira I, Inoue H. Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema. Ann Thorac Surg 1999;67:815–7. 4. Vaughn CC, Vaughn PL, Vaughn CC 3rd, Sawyer P, Manning M, Anderson D. Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 1998;13:259– 65. 5. Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573–5. 6. Horio H, Nomori H, Fuyuno G, Kobayashi R, Castel-Dupont S. Intrapulmonary hematoma surrounding the stapled line after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax. Kyobu Geka 1999;52:477– 80. 7. Nguyen H, Nguyen HV, Barra JA, Raut Y, Morinaga S, © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
1695
Suemasu K. Absorbable synthetic clips and pulmonary excision. Our clinical experience. Chir (Paris) 1987;124:113– 8.
Redoing Reconstruction of the Esophagus Using Remnants of the Ileo-Left Colon Aided by Microvascular Anastomosis Yau-Lin Tseng, MD, Ming-Ho Wu, MD, Mu-Yen Lin, MD, and Jing-Wei Lee, MD Divisions of Thoracic Surgery and Plastic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.
Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury. (Ann Thorac Surg 2001;71:1695–7) © 2001 by The Society of Thoracic Surgeons
T
he substitutes most commonly used for replacement of the esophagus include portions from the stomach, colon, and jejunum [1, 2]. On patients with corrosive injury in which the stomach is also frequently injured, the colon or jejunum is the best choice of graft material [3]. However, in cases involving failure of the colon graft or injury to the neoesophagus, surgeons may choose pedicled intestine, extended jejunum, or other flaps for reconstruction [4, 5]. We present a case in which we used remnant ileo-left colon for a second reconstruction of the esophagus. Although severe adhesions in the abdominal cavity may be present, reconstruction of the esophagus can be performed with available remnant alimentary tract with the aid of microvascular surgery. A 42-year-old female patient had a history of substernal ileocolon reconstruction for corrosive esophageal stricture ten years before (Fig 1). She was referred to our hospital ten days after drinking Drano drain cleaner for Accepted for publication July 15, 2000. Address reprint requests to Dr Tseng, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd, Tainan, Taiwan; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(00)02306-7
1696
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
Ann Thorac Surg 2001;71:1695–7
side cologastrostomy was then performed. Finally, the end of the remaining intraabdominal ileum was anastomosed to the sigmoid colon (Fig 2). A nasogastric tube was put into the stomach via the ileo-colon graft. Feeding was started on the 5th postoperative day. Esophagography revealed good passage of contrast medium on the 10th postoperative day. The patient started oral feeding on the 12th postoperative day. Wound infection was the only complication. After debridement and secondary closure of the wound, she was uneventfully discharged on the 27th postoperative day. She was able to swallow a regular diet and stool passage was occurring two to three times per day at the six-month follow-up.
Comment
Fig 1. The ileocolon interposition was performed ten years prior. Gray hatched area was resected on the second incidence of corrosive injury at our hospital.
In the 420 caustic injured patients at our hospital during the past 12 years, only three attempted suicide a second time with a corrosive agent. This patient was the only survivor. In treatment of corrosive esophageal stricture, we prefer to use the colon or ileo-colon as graft material for initial reconstruction because the stomach is always injured. Jejunum should be used as a backup when the colon graft is not available. We initially decided to use jejunal transposition for reconstruction in this patient. After lysis of the abdominal adhesions and careful evaluation of the jejunum, ileum, and colon, we found that the remaining left colon, which was supplied by the left
the second time. In the emergency department, she presented with sepsis and dyspnea. Physically, she had tachycardia (112/min), fever (39.2°C), tachypnea (42/min), pale conjuntiva and decreased breathing sounds in the right chest. Chest film revealed right pyopneumothorax. Arterial blood gas analysis showed pH 7.49, PCO2 37.6 mm Hg, PO2 34 mm Hg, Base excess ⫺6.6 mmol/L without oxygen supply. After tube thoracostomy (500 ml of dirty pus was drained), emergency right thoracotomy for resection of the neo-esophagus, decortication, and laparotomy for feeding gastrostomy were performed. The neoesophagus was necrotic and perforated. She did well after the operation and was discharged on the 36th postoperative day. Two and a half months after the second corrosive injury, she was admitted for reconstruction of the esophagus. After dissection of abdominal adhesions via midline laparotomy, we decided to use the remnant ileocolon as an interposed graft for reconstruction. The graft consisted of a segment of pedicled ileum, 12-cm in length, and left colon, 33 cm in length, which was anastomosed in the previous operation. The blood supply of the ileum and left colon graft was dependent on the ileal artery and in situ left colic artery, without an arcade connection between the ileul and left colonic segments. This graft was pulled up in front of the stomach to the neck via the substernal route. The transposed ileum was anastomosed to the esophagus. Then the ileal artery of the ileal pedicle was anastomosed to the transverse cervical artery, and the vein of the ileum was anastomosed to the external jugular vein with interrupted 9 – 0 Propylene; the left colic artery was left in situ. Warm ischemia time of the ileum was 45 minutes. End to
Fig 2. Redoing reconstruction of the esophagus after a second incidence of corrosive injury. (A) Blood vessels of the ileum; (B) previous ileo-colostomy; (C) in situ leftcolic artery dependent colon; and (D) gray hatched area was the graft used in this operation.
Ann Thorac Surg 2001;71:1797– 8
CASE REPORT GRONDIN ET AL ECTOPIC INTRATHORACIC GOITER
1697
colic artery, was doing well but its length was not enough to reach the cervical esophageal stump. In this situation, free intestinal transfer was a choice to add length of the colon graft [6, 7]. To simplify the operative procedure, we chose the remnant ileo-colon instead of a free jejunal transfer. The functional result of this patient is good during outpatient follow-up. We recommend this surgical technique, as a good alternative for reconstructing the esophagus a second time.
References 1. Wilkins EW. Technique of esophageal reconstruction. In: Zuidema GD, ed. Surgery of the alimentary tract. 3rd ed. Philadelphia: WB Saunders, 1991:387– 407. 2. Akiyama H, Hiayama M, Miyazono H. Total esophageal reconstruction after extraction of the esophagus. Ann Surg 1984;182:547–52. 3. Wu MM, Lai WW. Esophageal reconstruction for esophageal stricture or resection after corrosive injury. Ann Thorac Surg 1992;53:798 – 802. 4. Hirabayashi S, Miyata M, Shoji M, et al. Reconstruction of the thoracic esophagus, with extended jejunum used as a substitute, with the aid of microvascular anastomosis. Surg 1993; 113:515–17. 5. Gorbunov GN, Marinichev VL, Volkov ON, et al. Microvascular reconstruction of the esophagus with pedicled small intestine. Ann Plast Surg 1993;31:439– 42. 6. Ong GB, Lam KH, Lam PHM, et al. Resection for carcinoma of the superior mediastinal segment of the esophagus. World J Surg 1978;2:497–504. 7. Spencer PW, Fisher J. Esophageal reconstruction: free jejunal transfer or circulatory augmentation of pedicled intestinal interposition using microvascular surgery. In: Delarue NC, ed. Esophageal cancer-International trends in general thoracic surgery, volume 4. St. Louis: CV Mosby, 1988;30:250 –5.
Thoracoscopic Resection of an Ectopic Intrathoracic Goiter Sean C. Grondin, MD, Percival Buenaventura, MD, and James D. Luketich, MD The Mark Ravitch/Leon C. Hirsch Center for Minimally Invasive Surgery and the Section of Thoracic Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
We report a case of an ectopic intrathoracic goiter in a 79-year-old human. This uncommon finding presented as a symptomatic paratracheal mass that was resected using thoracoscopic techniques without complication. (Ann Thorac Surg 2001;71:1697– 8) © 2001 by The Society of Thoracic Surgeons
M
ediastinal thyroid neoplasms are uncommon tumors that account for approximately 6% of mediastinal masses in adults [1]. Most of these tumors arise secondary to downward growth into the superior mediAccepted for publication June 21, 2000. Address reprint request to Dr Luketich, Section of Thoracic Surgery, University of Pittsburgh Medical Center, C-800 Presbyterian University Hospital, 200 Lothrop St, Suite C 800 PUH, Pittsburgh, PA 15213–3221; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Computed tomography (CT) of the chest demonstrating high attenuation mass within the superior mediastinum between the right subclavian vein and brachiocephalic artery.
astinum from the thyroid gland in the neck (i.e., substernal goiter). Rarely, an ectopic thyroid tumor develops in the thorax distinct from the cervical thyroid gland. We describe a case of an ectopic superior mediastinal thyroid tumor successfully resected via a thoracoscopic approach. The patient, a 79-year-old woman, presented with a one month history of progressive upper back pain. Her past medical history was significant for hypertension and stable coronary artery disease. Physical examination was unremarkable. Bloodwork, including thyroid function studies, was normal. A chest roentgenogram did not demonstrate any significant abnormalities. Computed tomography (CT) of the chest demonstrated a 3 ⫻ 1.5 cm high attenuation mass within the superior mediastinum located between the right subclavian vein and brachiocephalic artery with no evidence of invasion or adenopathy (Fig 1). A sestamibi thyroid scan demonstrated a normal cervical thyroid gland with separate uptake in the right upper mediastinum at the site of the mediastinal lesion (Fig 2). Following a satisfactory preoperative evaluation which included a negative stress thallium test, a thoracoscopic resection was planned. At the time of surgery, bronchoscopy was normal. A double lumen endotracheal tube was placed and the patient positioned in a right lateral decubitus position. A video-assisted approach was chosen using four access ports (three 5 mm and one 10 mm port) carefully positioned in the upper thorax near the axilla to allow visualization of the paratracheal and upper parasternal areas. Dissection posterior to the superior vena cava was performed taking care not to injure the phrenic nerve. Dissection around the right tracheoesophageal groove identified one paratracheal lymph node that was sampled and found to be pathologically negative. A wellencapsulated mass that corresponded to the mass noted on preoperative CT scan was subsequently mobilized. One major feeding vessel arising from the right innominate artery was isolated, clipped, and divided. There was no cervical extension. The mass was removed en bloc without complication. Postoperatively, the patient had an uncomplicated course and was discharged on postoperative day two. The patient was found to be asymptomatic with resolution of her back pain at 1 and 6 months 0003-4975/01/$20.00 PII S0003-4975(00)02298-0